Testosterone therapy at the time of vasectomy reversal: Impact on intraoperative decision-making and interpretation of postoperative outcomes

INTRODUCTION: During vasectomy reversal (VR), accurate intraoperative microscopic assessment of the vasal fluid for sperm presence and quality is essential in determining the indication for a vasovasostomy (VV) or vasoepididymostomy (VE). The use of testosterone therapy (TT), known to supress spermatogenesis, can potentially interfere with this determination. This initiative evaluated the impact of TT on vasal and epididymal fluid sperm characteristics and intraoperative decision-making among men on TT at the time of VR. METHODS: Of 2622 consecutive VRs performed from 2007-2023, patients actively using TT at the time of VR were identified. Details as to the type, dose, and duration of TT were documented. All patients were counselled regarding the impact of TT on spermatogenesis and encouraged to discontinue TT if possible. During VR, vasal and epididymal fluid (as indicated) was sampled and each aspirate underwent microscopic evaluation for sperm presence and quality, and categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. Rates of sperm presence/absence in the vasal/epididymal fluid, frequency of VV/VE, postoperative patency (presence of motile sperm), and semen parameters were compared among patients on TT vs. clinically matched patients not using TT at the time of VR. RESULTS: Among the 2622 VRs reviewed, 54 men (2%) reported using TT at the time of their VR. Despite its impact on spermatogenesis, intraoperative microscopic analysis of the reproductive fluid (vasal or epididymal) identified the presence of sperm in 95% (51/54) of patients. Testis biopsy confirmed sperm production among three patients with absence of sperm within the vasal or epididymal fluid. Rates of VV or VE did not significantly differ among men using TT at the time of VR compared to non-users. Postoperative patency rates (TT: 78 % vs. no TT: 93%) and mean total motile sperm counts (TMC) were lower among patients using TT at the time of VR (7.9 vs. 28.3, p=0.02). CONCLUSIONS: Use of TT at the time of VR does not appear to impact rates of intraoperative microscopic identification of sperm within the reproductive fluid or the indication for VV/VE. Postoperative patency rates and TMC may be lowered by use of TT. Moreover, the determination to the etiology azoospermia postoperatively (production vs. obstruction) may be clouded by the use of TT during VR.